The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2025.
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures: 15011, 15012
H. Eyelid & ocular surgery: 66683
P. CAR-T Therapy: 38225, 38226, 38227, 38228
Q. Urology: 51721, 53865, 53866, 55881, 55882
R. Other: 60660, 60661
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
4. Gastroenterology Procedures: 42975
H. Therapeutic Services:
3. Pain Management Codes (i.e. injections, TENS, therapeutic services): 64466, 64467, 64468, 64469, 64473, 64474
The following codes have been added to the Medicaid DME Authorization Grid:
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E0651
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Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
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E0652
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Electrode for external lower extremity nerve stimulator for restless legs syndrome
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The following codes have been added to the Medicaid, CHP, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:
J0601 sevelamer carbonate, oral, ESRD on Dialysis (Renvela)
J0602 sevelamer carbonate, oral powder, ESRD on Dialysis (Renvela)
J0603 sevelamer carbonate, oral, ESRD on Dialysis (Renagel)
J0605 sucroferric oxyhydroxide, oral, ESRD on Dialysis
J0607 lanthanum carbonate, oral, ESRD on Dialysis
J0608 lanthanum carbonate, oral powder, ESRD on Dialysis
J0609 ferric citrate, oral, ESRD on Dialysis
J0615 calcium acetate, oral, ESRD on Dialysis
J0901 vadadustat, oral, ESRD on Dialysis (Vafseo)
The following codes have been added to the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization:
C9173 filgrastim-txid (Nypozi)
J0139 adalimumab (Humira)
J0870 imetelstat (Rytelo)
J1307 crovalimab-akkz (Piasky)
J1414 fidanacogene elaparvovec-dzkt (Beqvez)
J1552 immune glob (Alyglo)
J2802 romiplostim (Nplate)
J3392 exagamglogene autotemcel (Casgevy)
J7514 mycophenolate mofetil 100 mg (Myhibbin)
J7601 ensifentrine (Ohtuvayre)
J9026 tarlatamab-dlle (Imdelltra)
J9028 nogapendekin alfa inbakicept-pmln (Anktiva)
J9076 cyclophosphamide (Baxter)
J9292 pemetrexed inj (Avyxa)
Q0155 dronabinol oral (Syndros)
Q0521 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription
Q5139 eculizumab-aeeb (Bkemv)
Q5140 adalimumab-fkjp (Hulio)
Q5141 adalimumab-aaty (Yuflyma)
Q5142 adalimumab-ryvk (Simlandi)
Q5143 adalimumab-adbm (Cyltezo)
Q5144 adalimumab-aacf (Idacio)
Q5145 adalimumab-afzb (Abrilada)
Q5146 trastuzumab-strf (Hercessi)
Q9996 ustekinumab SUBQ (Pyzchiva)
Q9997 ustekinumab IV (Pyzchiva)
Q9998 ustekinumab (Selarsdi)
Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Products:
C9173 filgrastim-txid (Nypozi)
J0870 imetelstat (Rytelo)
J9026 tarlatamab-dlle (Imdelltra)
J9028 nogapendekin alfa inbakicept-pmln (Anktiva)
J9076 cyclophosphamide (Baxter)
J9292 pemetrexed inj (Avyxa)
Q0155 dronabinol oral (Syndros)
Q5146 trastuzumab-strf (Hercessi)
Visit: Authorization Grids